Professional Review

Lateral Positioning of the Nasal Using Digital

Wendy Mickelsen, MHE, R.T.(R)(M) Dan Hobbs, MSRS, R.T.(R)(CT)(MR) Christopher Wertz, MSRS, R.T.(R)

he nasal bones consist of 2 fused bones that help to form the bridge of the nose and can vary in size among adults (see Figure 1).1 T Because the nose is a prominent facial feature, it is often the site of trauma. The nasal bones are the most commonly fractured facial bones, and these frac- tures are statistically more prevalent among men than women, at a ratio of 2:1, with a significant peak in the 15- to 25-year-old male population.2,3 Adult nasal frac- tures typically result from altercations, sports , motor vehicle accidents, and falls. The degree of force required to fracture the nasal bones is relatively small (25-75 lb of pressure) compared with the surrounding midfacial structures.3 Patients with nasal fractures usu- ally exhibit some degree of deformity, tenderness, hem- orrhage, , and instability.4 In radiography, imaging the nasal bones is common. Typical protocol includes a Waters or Caldwell and bilat- Figure 1. Anatomy of the nasal bones. Reprinted with permission eral lateral images. Both sides of the nasal bones are exam- from Visible Body. ined for comparison.5 Over the years, using film-screen techniques and theory, educators taught positioning of radiography has enabled technologists to modify their the lateral nasal bones with the patient lying semiprone on examination protocols. Consequently, lateral nasal the table with his or her head turned into either a left or positions can be achieved easily and with some ingenu- right lateral position. Many newer radiography positioning ity using computed and direct imaging receptors. books still demonstrate this practice. However, for injured, elderly, or immobile patients, this position is difficult. Computed Radiography For computed radiography, a technologist places Digital Imaging Receptors an 8 × 10-inch imaging plate into the upright Bucky, Lateral positioning of the nasal bones can be per- setting it directly onto the bottom lip of the cassette formed in a variety of ways. The advent of digital holder. The imaging plate should be pulled out of the

RADIOLOGIC TECHNOLOGY, July/August 2013, Volume 84, Number 6 631 Professional Review Lateral Positioning of the Nasal Bones Using Digital Radiography

Bucky, maintaining a nongrid exposure technique. A With a patient either standing or sitting, the technolo- gist must adjust the height of the pulled-out Bucky until it rests directly above the patient’s . The patient’s cheek should be placed directly against the imaging plate. The technologist should position the nasal bones on the center of the imaging plate and adjust the patient’s head into a true lateral position, ensuring that the inter- pupillary line is perpendicular to the imaging plate. The technologist must then collimate to the anatomical area of interest (see Figure 2). Exposure factors should be similar to those of a finger exposure technique (ie, low B kVp, low mAs, and small focal spot). The exposure is repeated on the contralateral nasal bone for comparison purposes. For facilities using film-screen, this same technique can be used with a detail cassette in the upright Bucky in lieu of a computed radiography imaging plate.

Direct Radiography For direct radiography of the lateral nasal bones performed at the upright Bucky, a technologist must remove the grid to facilitate a nongrid exposure tech- nique (see Figure 3). As with computed radiography, Figure 2. A. Computed radiography imaging plate placed on the exposure factors should be similar to those of a finger cassette holder of the upright Bucky (arrow). B. Model is standing in a right lateral nasal bone position. Imaging plate remains in a pulled- exposure technique (see Figure 4). out position to use nongrid exposure factors; image receptor is directly The technologist should position the patient with above the shoulder. the nasal bones in the center of the direct radiogra- phy flat panel (see Figure 5). Some imaging facilities prefer not to remove the upright Bucky grid because of the replacement cost if it is dropped or damaged. In that case, a wireless detector could be used. The technologist would place the wireless detector on the rollaway holder and position the patient supine on the radiographic table with the detector directly against the downside nasal bone (ie, the one closest to the image receptor) (see Figure 6). Both sides of the nasal bones are imaged. Immed- iately after the detector is exposed, the radiograph will appear on the technologist’s workstation monitor (see Figure 7). Conclusion With advances in technology, film-screen cassettes Figure 3. Grid is removed from upright flat-panel direct-radiography are becoming outdated. Wireless detectors and imaging detector.

632 RADIOLOGIC TECHNOLOGY, July/August 2013, Volume 84, Number 6 Professional Review Mickelsen, Hobbs, Wertz

A

B Figure 4. X-ray tube head demonstrating digital display of nasal bone exposure factors: 52 kVp, 3.2 mAs, small focal spot.

Figure 6. A. Wireless detector placed on a rollaway holder. B. Wireless detector in position for an x-table digital image of the left lateral nasal bone.

Figure 5. Model is in a right lateral position next to direct radiography detector, with the grid removed from the upright Bucky. plates provide opportunities for students and technolo- gists to explore innovative ways to perform traditional studies. The result can make the examination easier and more efficient for both patient and technologist. Although obtaining images of the nasal bones is rela- tively straightforward, the techniques suggested in this article offer an easy approach for improving the process.

Wendy Mickelsen, MHE, R.T.(R)(M), is a clinical assistant professor and clinical coordinator for the Radiographic Science Program at Idaho State University and a mammography and staff technologist at Eastern Figure 7. Left lateral nasal bones of an x-ray phantom demonstrated Idaho Regional Medical Center in Idaho Falls. on the technologist’s workstation monitor.

RADIOLOGIC TECHNOLOGY, July/August 2013, Volume 84, Number 6 633 Professional Review Lateral Positioning of the Nasal Bones Using Digital Radiography

Dan Hobbs, MSRS, R.T.(R)(CT)(MR), is the program director for the Radiographic Science Program at Idaho State University. Christopher Wertz, MSRS, R.T.(R), is an adjunct facul- ty member for the Radiographic Science Program at Idaho State University and a staff technologist at Mountain View REDICARE in Idaho Falls. References 1. Bontrager KW, Lampignano JP. Radiographic Positioning and Related Anatomy. 7th ed. St Louis, MO: Mosby Inc; 2010: 401-444. 2. Eisenberg R, Johnson N. Comprehensive Radiographic Pathology. 5th ed. St Louis, MO: Mosby Inc; 2012:320. 3. Mathog R, Arden R, Marks S. Trauma of the Nose and Paranasal Sinuses. New York, NY: Thieme Medical Publishers; 1995:23-25. 4. Smith J, Perez C. Nasal fracture imaging. eMedicine website. http://emedicine.medscape.com/article/391863. Accessed December 15, 2012. 5. Ballinger PW, Frank ED. Merrill’s Atlas of Radiographic Positions and Radiologic Procedures. 12th ed. St Louis, MO: Mosby-Year Book Inc; 2012:323-336.

634 RADIOLOGIC TECHNOLOGY, July/August 2013, Volume 84, Number 6